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Oda T, Tamura N, Yata D, Oda-Kishimoto A, Itoh T, Kubota N, Suzuki Y, Kanayama N, Itoh H. A Case of Consumptive Coagulopathy Before Cardiopulmonary Failure in Amniotic Fluid Embolism and Review of Literature: A Perspective of the Latent Onset and Progression of Coagulopathy. Cureus 2024; 16:e55961. [PMID: 38601376 PMCID: PMC11004845 DOI: 10.7759/cureus.55961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 04/12/2024] Open
Abstract
Amniotic fluid embolism (AFE) induces cardiopulmonary insufficiency with consumptive coagulopathy. Previous studies reported that refractory coagulopathy has already advanced at the onset of maternal cardiovascular and/or respiratory symptoms. However, when the consumption of coagulation factors starts during the clinical course, AFE remains to be elucidated. We report an intrapartum AFE case of consumptive coagulopathy before dyspnea with hypotension developing during urgent cesarean delivery that was revealed by non-reassuring fetal heart rate tracing. The patient, a 42-year-old multiparous parturient, underwent induced labor after a premature rupture of membranes in week 39 of pregnancy. Coagulation screening was initially within the normal range. Fetal heart rate monitoring demonstrated bradycardia coincided with uterine tachysystole after three hours, which required urgent cesarean section with preoperative blood screening. The hemoglobin level was maintained at 129 g/L; however, the fibrinogen value reduced to 1.79 g/L with D-dimer elevation over 60 µg/mL. Ninety minutes later, she developed dyspnea with hypotension at suturing hysterotomy. At the end of surgery, her fibrinogen further decreased to below 0.3 g/L with prolonged prothrombin time. After vigorous intensive care, she was discharged without sequelae. Consumptive coagulopathy may initiate and progress before apparent cardiopulmonary symptoms in some AFE cases. Non-reassuring fetal heart rate tracing concomitant with abrupt uterine tachysystole and/or hypertonus may be an earlier time point for the detection and intervention of AFE-related coagulopathy.
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Affiliation(s)
- Tomoaki Oda
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, JPN
- Department of Obstetrics and Gynecology, Fuji City General Hospital, Fuji, JPN
| | - Naoaki Tamura
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, JPN
| | - Daisuke Yata
- Department of Obstetrics and Gynecology, Fuji City General Hospital, Fuji, JPN
| | - Ayako Oda-Kishimoto
- Department of Obstetrics and Gynecology, Fuji City General Hospital, Fuji, JPN
| | - Toshiya Itoh
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, JPN
- Department of Obstetrics and Gynecology, Fuji City General Hospital, Fuji, JPN
| | - Naohiro Kubota
- Department of Obstetrics and Gynecology, Fuji City General Hospital, Fuji, JPN
| | - Yasuyuki Suzuki
- Department of Obstetrics and Gynecology, Fuji City General Hospital, Fuji, JPN
| | - Naohiro Kanayama
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, JPN
- Department of Obstetrics and Gynecology, Fuji City General Hospital, Fuji, JPN
| | - Hiroaki Itoh
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, JPN
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Buechel J, Monod C, Alba Alejandre I, Ninke T, Hoesli I, Starrach T, Delius M, Mahner S, Kaltofen T. Amniotic Fluid Embolism: a comparison of two classification systems in a retrospective 8-year analysis from two tertiary hospitals. J Gynecol Obstet Hum Reprod 2023; 52:102597. [PMID: 37087046 DOI: 10.1016/j.jogoh.2023.102597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 04/15/2023] [Accepted: 04/19/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVE Amniotic fluid embolism (AFE) is a rare life-threatening complication in obstetrics, but the diagnosis lacks a consensual definition. The objective of this study was to compare two different AFE classification systems by analysing the AFE cases from two university hospitals. MATERIAL AND METHODS In this retrospective study, all patients with a strong suspicion of AFE between 2014 and 2021 at two university hospitals, LMU Women's University Hospital Munich, and Women's University Hospital Basel, were included. Patient records were checked for the ICD-10 code O88.1 (AFE). Diagnoses were confirmed through clinical findings and/or autopsy. The presence of the diagnostic criteria of the Society of Maternal Fetal Medicine (SMFM) and the AFE Foundation (AFEF) and of a new framework by Ponzio-Klijanienko et al. from Paris, France, were checked and compared using Chi-square-test. RESULTS Within our study period, 38,934 women delivered in the two hospitals. Six patients had a strong suspicion of AFE (0.015%). Only three of six patients (50%) presented with all the four diagnostic criteria of the SMFM/AFEF framework. All six patients met the criteria of the modified "Paris AFE framework". CONCLUSION Using the "Paris AFE framework" based exclusively on clinical criteria can help clinicians to diagnose AFE, anticipate the life-threatening condition of the patient and prepare immediately for best clinical care.
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Affiliation(s)
- J Buechel
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - C Monod
- Department of Obstetrics and Antenatal Care, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland; Medical Faculty, University Basel, Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland
| | - I Alba Alejandre
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - T Ninke
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - I Hoesli
- Department of Obstetrics and Antenatal Care, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland; Medical Faculty, University Basel, Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland
| | - T Starrach
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - M Delius
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - S Mahner
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - T Kaltofen
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany; Department for Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
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Zhu C, Xu D, Luo Q. Fatal amniotic fluid embolism: incidence, risk factors and influence on perinatal outcome. Arch Gynecol Obstet 2023; 307:1187-1194. [PMID: 35397752 DOI: 10.1007/s00404-022-06535-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 03/16/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE This study aimed to estimate the incidence of fatal amniotic fluid embolism, describe its risk factors, and analyze perinatal outcomes. METHODS Maternity cases and newborn records of amniotic fluid embolism were collected from the Zhejiang Maternal Surveillance System from October 2006 to October 2019. This study strictly limited the diagnostic criteria for AFE and excluded suspicious cases in order to minimize false-positive AFE cases. The risk factors of fatal amniotic fluid embolism and the relationship between perinatal prognosis and AFE were investigated using logistic regression analysis, estimating the adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS 149 cases of amniotic fluid embolism were registered, of which 80 cases were fatal. The estimated fatal AFE incidence was 0.99 per 100,000. The occurrence of fatal AFE was significantly correlated with spontaneous vaginal delivery (aOR 12.3, 95% CI 3.3-39.2) and cardiac arrest (aOR 64.8, 95% CI 14.6-287.8). The average diagnosis time of fatal AFE is 85.51 min, and the peak period of female death is 1-12 h after the onset of the disease, accounting for 60% (48/80) of cases. Fatal amniotic embolism is a cause of intrauterine fetal death and fetal death during delivery (aOR 11.957, 95% CI 1.457-96.919; aOR 13.152, 95% CI 1.636-105.723). Of the 149 confirmed AFE cases, 11 cases of stillbirth occurred, 12 cases were stillborn, and 7 cases of neonatal death were reported. The perinatal mortality rate was 202 per 1000. CONCLUSIONS Early detection, diagnosis, and treatment of amniotic fluid embolism are essential to avoiding fatal AFE. Clinicians should fully evaluate the pros and cons of choosing the delivery method for pregnant women. When cardiac arrest occurs in women with amniotic fluid embolism, obstetricians should be particularly careful and provide timely and effective treatment to minimize the fatality rate. The outcome of AFE is not only related to maternal survival but also plays a decisive role in the prognosis of the infant over the perinatal period.
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Affiliation(s)
- Chengya Zhu
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, No. 1 Xueshi Road, Hangzhou, 310000, China
| | - Dong Xu
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, No. 1 Xueshi Road, Hangzhou, 310000, China
| | - Qiong Luo
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, No. 1 Xueshi Road, Hangzhou, 310000, China.
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de Lloyd L, Jenkins PV, Bell SF, Mutch NJ, Martins Pereira JF, Badenes PM, James D, Ridgeway A, Cohen L, Roberts T, Field V, Collis RE, Collins PW. Acute obstetric coagulopathy during postpartum hemorrhage is caused by hyperfibrinolysis and dysfibrinogenemia: an observational cohort study. J Thromb Haemost 2023; 21:862-879. [PMID: 36696216 DOI: 10.1016/j.jtha.2022.11.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/21/2022] [Accepted: 11/13/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Postpartum hemorrhage (PPH) may be exacerbated by hemostatic impairment. Information about PPH-associated coagulopathy is limited, often resulting in treatment strategies based on data derived from trauma studies. OBJECTIVES To investigate hemostatic changes associated with PPH. PATIENTS/METHODS From a population of 11 279 maternities, 518 (4.6%) women were recruited with PPH ≥ 1000 mL or placental abruption, amniotic fluid embolism, or concealed bleeding. Routine coagulation and viscoelastometric results were collated. Stored plasma samples were used to investigate women with bleeds > 2000 mL or those at increased risk of coagulopathy defined as placenta abruption, amniotic fluid embolism, or need for blood components. Procoagulant factors were assayed and global hemostasis was assessed using thrombin generation. Fibrinolysis was investigated with D-dimer and plasmin/antiplasmin complexes. Dysfibrinogenemia was assessed using the Clauss/antigen ratio. RESULTS At 1000 mL blood loss, Clauss fibrinogen was ≤2 g/L in 2.4% of women and 6/27 (22.2%) cases of abruption. Women with very large bleeds (>3000 mL) had evidence of a dilutional coagulopathy, although hemostatic impairment was uncommon. A subgroup of 12 women (1.06/1000 maternities) had a distinct coagulopathy characterized by massive fibrinolysis (plasmin/antiplasmin > 40 000 ng/mL), increased D-dimer, hypofibrinogenemia, dysfibrinogenemia, reduced factor V and factor VIII, and increased activated protein C, termed acute obstetric coagulopathy. It was associated with fetal or neonatal death in 50% of cases and increased maternal morbidity. CONCLUSIONS Clinically significant hemostatic impairment is uncommon during PPH, but a subgroup of women have a distinct and severe coagulopathy characterized by hyperfibrinolysis, low fibrinogen, and dysfibrinogenemia associated with poor fetal outcomes.
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Affiliation(s)
- Lucy de Lloyd
- Department of Anaesthetics and Pain Control, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK
| | - Peter V Jenkins
- Department of Haematology, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK; Institute of Infection and Immunity, School of Medicine, Cardiff University, UK
| | - Sarah F Bell
- Department of Anaesthetics and Pain Control, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK
| | - Nicola J Mutch
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, UK
| | | | | | - Donna James
- Department of Obstetrics and Gynaecology, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK
| | - Anouk Ridgeway
- Department of Obstetrics and Gynaecology, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK
| | - Leon Cohen
- Department of Anaesthetics and Pain Control, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK
| | - Thomas Roberts
- Department of Anaesthetics and Pain Control, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK
| | - Victoria Field
- Department of Anaesthetics and Pain Control, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK
| | - Rachel E Collis
- Department of Anaesthetics and Pain Control, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK
| | - Peter W Collins
- Department of Haematology, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK; Institute of Infection and Immunity, School of Medicine, Cardiff University, UK.
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Collis R, Bell S. The Role of Thromboelastography during the Management of Postpartum Hemorrhage: Background, Evidence, and Practical Application. Semin Thromb Hemost 2023; 49:145-161. [PMID: 36318958 DOI: 10.1055/s-0042-1757895] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Postpartum hemorrhage (PPH) is a common cause of significant maternal morbidity and mortality that can be associated with coagulopathy, especially hypofibrinogenemia. There is interest in point-of-care viscoelastic hemostatic assays (POC-VHA) in PPH because prompt knowledge of coagulation status can aid diagnosis, identify cases of severe coagulopathy, and allow ongoing monitoring during rapid bleeding. The incidence of coagulopathy in most cases of PPH is low because of the procoagulant state of pregnancy, including raised fibrinogen levels of around 4 to 6 g/L. A Clauss fibrinogen of >2 g/L or POC-VHA equivalent has been found to be adequate for hemostasis during PPH. POC-VHA has been used successfully to diagnose hypofibrinogenemia (Clauss fibrinogen of ≤2 g/L) and guide fibrinogen treatment which has reduced bleed size and complications of massive transfusion. There are uncertainties about the use of POC-VHA to direct fresh frozen plasma and platelet administration during PPH. Several POC-VHA algorithms have been used successfully incorporated in the management of many thousands of PPHs and clinicians report that they are easy to use, interpret, and aid decision making. Due to the relative cost of POC-VHA and lack of definitive data on improving outcomes, these devices have not been universally adopted during PPH.
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Affiliation(s)
- Rachel Collis
- Department of Anaesthetics, University Hospital of Wales, Cardiff, United Kingdom
| | - Sarah Bell
- Department of Anaesthetics, University Hospital of Wales, Cardiff, United Kingdom
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Bouthors AS, Gilliot S, Sentilhes L, Hennart B, Jeanpierre E, Deneux-Tharaux C, Lebuffe G, Odou P. The role of tranexamic acid in the management of postpartum haemorrhage. Best Pract Res Clin Anaesthesiol 2022; 36:411-426. [PMID: 36513435 DOI: 10.1016/j.bpa.2022.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 12/15/2022]
Abstract
In the last decades, tranexamic acid (TXA) has emerged as an essential tool in blood loss management in obstetrics. TXA prophylaxis for postpartum haemorrhage (PPH) has been studied in double-blind, placebo-controlled, randomized clinical trials (RCTs). Given the small observed preventive effect, the systematic use of TXA for vaginal and/or caesarean deliveries remains controversial. The result of a pharmacokinetic modelling suggests that relative to intravenous administration, intramuscular administration may be an equally effective alternative route for preventing PPH and may enable access to this drug in low-resource countries. Prophylaxis is currently studied in high-risk populations, such as women with prepartum anaemia or placenta previa. TXA effectively reduces blood loss and PPH-related morbidity and mortality during active PPH, as demonstrated by high-grade evidence from large RCTs. The drug has a good safety profile: in most cases, only mild gastrointestinal or visual adverse events may be observed. TXA use does not increase the risk of serious adverse events, such as venous or arterial thromboembolism, seizures, or acute kidney injury. The TRACES in vivo analysis of biomarkers of TXA's antifibrinolytic effect have suggested that a dose of at least 1 g is required for the treatment of PPH. The TRACES pharmacokinetic model suggests that because TXA can be lost in the haemorrhaged blood, a second dose should be administered if the PPH continues or if severe coagulopathy occurs. Future pharmacodynamic analyses will focus on the appropriateness of TXA dosing regimens with regard to the intensity of fibrinolysis in catastrophic obstetric events.
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Affiliation(s)
- Anne-Sophie Bouthors
- Anaesthesia Intensive Care Unit, Jeanne de Flandre Women's Hospital, Lille University Medical Centre, F-59037, Lille, France; Univ. Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000, Lille, France.
| | - Sixtine Gilliot
- Univ. Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000, Lille, France; Central Pharmacy, Lille University Medical Centre, F-59037, Lille, France.
| | - Loïc Sentilhes
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, F-33076 Bordeaux, France
| | - Benjamin Hennart
- Toxicology Unit, Biology and Pathology Centre, Lille University Medical Centre, F-59037, Lille, France
| | - Emmanuelle Jeanpierre
- Haemostasis Unit, Biology and Pathology Centre, Lille University Medical Centre, F-59037, Lille, France
| | - Catherine Deneux-Tharaux
- Université Paris Cité, CRESS UMR 1153, Obstetrical Perinatal and Paediatric Epidemiology Research Team, EPOPé, INSERM, F75014 Paris, France
| | - Gilles Lebuffe
- Univ. Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000, Lille, France; Anaesthesia and Intensive Care Unit, Lille University Medical Centre, F-59037 Lille, France
| | - Pascal Odou
- Univ. Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000, Lille, France; Central Pharmacy, Lille University Medical Centre, F-59037, Lille, France
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7
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Point-of-care coagulation testing for postpartum haemorrhage. Best Pract Res Clin Anaesthesiol 2022; 36:383-398. [PMID: 36513433 DOI: 10.1016/j.bpa.2022.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/03/2022] [Accepted: 08/05/2022] [Indexed: 12/15/2022]
Abstract
The use of viscoelastic haemostatic assays (VHAs) to guide blood product replacement during postpartum haemorrhage is expanding. Rotem and TEG devices can be used to detect and treat clinically significant hypofibrinogenaemia, although evidence to support the role of VHAs for guiding fresh frozen plasma and platelet transfusion is less clear. If Rotem/TEG traces are normal, clinicians should investigate for another cause of bleeding, and haemostatic support is not required. Guidelines support the use of VHAs during postpartum haemorrhage as part of locally agreed algorithms. There is a wide consensus that fibrinogen replacement is needed if the Fibtem A5 is <12 mm and if there is ongoing bleeding. Guidelines recommend against using VHAs to guide tranexamic acid infusion, and this drug should be given as soon as bleeding is recognised, irrespective of the Rotem/TEG traces. The cost-effectiveness of VHAs during postpartum haemorrhage needs to be addressed.
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Oliver C, Freyer J, Murdoch M, De Lloyd L, Jenkins PV, Collis R, Collins PW. A description of the coagulopathy characteristics in amniotic fluid embolism: a case report. Int J Obstet Anesth 2022; 51:103573. [PMID: 35842347 DOI: 10.1016/j.ijoa.2022.103573] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 06/07/2022] [Accepted: 06/24/2022] [Indexed: 11/19/2022]
Abstract
Amniotic fluid embolism is frequently associated with coagulopathy. However, the exact nature and evolution of the bleeding disorder is incompletely understood. We report a case of clinically diagnosed amniotic fluid embolism associated with major haemorrhage and coagulopathy. We measured sequential levels of all individual clotting factors, thrombin generation, fibrinogen, and D-dimer levels over the course of the event, beginning shortly after the patient's initial collapse and during the subsequent resuscitation, to identify the specific abnormalities of coagulation from stored blood samples. A better understanding of amniotic fluid embolism and the associated coagulopathy is an important area of research to inform targeted treatment of the coagulopathy and improve outcomes for patients.
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Affiliation(s)
- C Oliver
- Department of Anaesthesia, University Hospital of Wales, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK.
| | - J Freyer
- Department of Anaesthesia, University Hospital of Wales, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK
| | - M Murdoch
- Department of Anaesthesia, University Hospital of Wales, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK
| | - L De Lloyd
- Department of Anaesthesia, University Hospital of Wales, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK
| | - P V Jenkins
- Department of Haematology, University Hospital of Wales, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK
| | - R Collis
- Department of Anaesthesia, University Hospital of Wales, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK
| | - P W Collins
- Department of Haematology, University Hospital of Wales, Cardiff and Vale University Health Board, Heath Park, Cardiff, UK
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Oliver C, Freyer J, Murdoch M, Jenkins V, Collins P, DeLloyd L, Collis R. P.122 Amniotic fluid embolism: A description of coagulopathy. Int J Obstet Anesth 2021. [DOI: 10.1016/j.ijoa.2021.103120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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10
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Tschöp J, Lier H, Annecke T. Anästhesiologisches Management der Fruchtwasserembolie. Anasthesiol Intensivmed Notfallmed Schmerzther 2020; 55:674-685. [PMID: 33242901 DOI: 10.1055/a-1070-6843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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